Nursing Elites

1. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?

• A. Teaching the patient to take a temperature
• B. Teaching the patient to select nutritious foods
• C. Teaching the patient about the effects of alcohol
• D. Teaching the patient about fall prevention

Correct answer: B

Rationale: The correct answer is B: Teaching the patient to select nutritious foods. A nutritious diet plays a crucial role in strengthening the body's immune system, making it more capable of fighting off infections. Vitamins, minerals, and other nutrients found in healthy foods support immune function and overall health. Teaching the patient about taking a temperature (choice A) may be important for monitoring for signs of infection but does not directly decrease the risk of infection. Teaching about the effects of alcohol (choice C) and fall prevention (choice D) are important aspects of patient education but are not directly related to decreasing the risk of infection in a susceptible patient.

2. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?

• A. I should call 911 if my grandchild loses consciousness.
• B. Never induce vomiting if my grandchild drinks bleach.
• C. If my grandchild eats a plant, I should provide syrup of ipecac.
• D. The number for poison control is 800-222-1222.

Correct answer: C

Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.

3. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

• A. Self-report of pain
• B. Nonverbal behavior
• C. Severity of the condition
• D. Vital signs

Correct answer: A

Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.

4. While reviewing notes from a previous shift, a nurse finds incomplete documentation. What is the most appropriate action?

• A. Complete the missing documentation
• B. Notify the nurse manager of the issue
• C. Ask the nurse to complete the documentation
• D. Confront the nurse about the incomplete notes

Correct answer: B

Rationale: The most appropriate action when finding incomplete documentation is to notify the nurse manager of the issue. This ensures that accurate records are maintained and the situation can be addressed properly. Completing the missing documentation on behalf of someone else may lead to inaccuracies, asking the nurse to complete it may not guarantee timely correction, and confronting the nurse could create a confrontational situation that is not conducive to effective teamwork.

5. A healthcare provider is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL
• B. Absent urinary output for 1 hour
• C. Cloudy urine
• D. Bloody urine

Correct answer: A

Rationale: The correct answer is A. A large bladder scan result (525 mL) suggests catheter blockage and may require irrigation to resolve. Choice B (absent urinary output for 1 hour) could indicate a different issue such as urinary retention but does not specifically indicate the need for catheter irrigation. Choices C (cloudy urine) and D (bloody urine) may suggest infection or other urinary issues, but they do not directly indicate the need for catheter irrigation.

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